Introduction

Iliac crest bone graft harvest(ICBGH) is a common component of foot and ankle reconstruction. The harvest site is innervated by branches of the subcostal(T12), iliohypogastric, and ilioinguinal(L1) nerves.[1,2] Iliac crest pain can be a major source of postoperative discomfort, opioid use, and prolonged PACU stay, even when primary surgical site pain is well-controlled.[3,4] The transversalis fascia plane(TFP) block targets the nerves innervating the iliac crest and has emerged as a promising technique for donor-site analgesia.[2,4]

Materials and Methods

The patient provided informed consent for publication. Because no identifiable information is included, this report is exempt from institutional review under UNC policy.

Results/Case Report

A 48-year-old woman with depression, anxiety, fibromyalgia, chronic pain, and opioid-dependence underwent revision subtalar arthrodesis with ICBGH. Her history included two prior ankle surgeries with ICBGH. Both times she reported that popliteal nerve blocks provided excellent lower-extremity analgesia, but failed to address severe postoperative ICBGH pain.

For the current case, a popliteal nerve block was performed preoperatively. In PACU, the patient reported 0/10 pain in the foot, but 8/10 pain at the iliac crest, which she described as “very similar” to her prior surgeries.

A unilateral ultrasound-guided TFP rescue block was performed. With the patient supine, a curvilinear 5-1MHz ultrasound transducer was placed above the iliac crest. The relevant anatomy was identified(Figure-1). A 22-gauge echogenic needle was advanced in-plane deep to the transversus abdominis and into the TFP(Figure-2a). After negative aspiration, a 20mL mixture of plain bupivacaine with liposomal bupivacaine was injected(Figure-2b).

Within minutes, her pain decreased from 8/10 to 3/10. On exam, she developed numbness from the inguinal crease to the umbilicus and lateral hip. She described the block as making a "night and day difference," and was discharged home shortly thereafter. Upon follow-up, she reported return of "superficial sensation" around midnight, and "deeper bone pain" the next morning.

Discussion

Overall, the patient described her pain-relief as "dramatically superior" to her prior surgeries. She found the pain “much more bearable" and "wished 100-times-over" the she received the block for her prior ICBGH procedures.

The TFP block is simple to perform, carries minimal risk under ultrasound-guidance, and represents a valuable addition to multimodal analgesia for ICBGH pain. It remains underutilized in clinical practice and should be considered preoperatively for any procedure involving the iliac crest.

References

1. Chin KJ, Chan V, Hebbard P, Tan JS, Harris M, Factor D. Ultrasound-guided transversalis fascia plane block provides analgesia for anterior iliac crest bone graft harvesting. Can J Anaesth/J Can Anesth. 2012;59(1):122–123. doi:10.1007/s12630-011-9610-7.
2. Hebbard PD. Transversalis fascia plane block, a novel ultrasound-guided abdominal wall nerve block. Can J Anaesth/J Can Anesth. 2009;56(8):618–620. doi:10.1007/s12630-009-9110-1
3. Morgan SJ, Jeray KJ, Saliman LH, Miller HJ, Williams AE, Tanner SL, et al. Continuous infusion of local anesthetic at iliac crest bone-graft sites for postoperative pain relief: a randomized, double-blind study. J Bone Joint Surg Am. 2006;88:2606–2612. doi:10.2106/JBJS.E.00984.
4. Kumari A, Kumar J, Kumar A, Swati, Raghwendra KHR. Efficacy of transversalis fascia plane block for postoperative analgesia in iliac crest bone grafting: a triple blind, prospective randomized study. South East Eur J Public Health. 2025;26(S1):3859–3868.